Medicare Compliance & Reimbursement

Question: When the NP provides unsupervised services, I bill the codes under the nurse practitioner’s number for supervised visits, I use modifier SA. Would I bill using the rendering or the supervising provider’s NPI? Will payers reduce payment since this is not a supervised visit?

Answer: You should use HCPCS Level II modifier SA (Nurse practitioner rendering service in collaboration with a physician) for supervised nurse practitioner services when the insurer does require this modifier. Some Medicaid programs such as Medi-Cal require you to apply modifier SA to all nurse practitioner (NP) services which are submitted under the physician provider number. Do not use this modifier for Medicare patients as this modifier is not covered or valid for Medicare and as such reimbursement may be denied.

Example: A nurse practitioner provides a level three established patient office visit to a Medi-Cal patient. The NP’s urologist supervises the service. To indicate the NP provided the office visit under direct supervision, you would append modifier SA to 99213.

Use modifier SA for incident-to services that are billed under the supervising physician’s NPI number. The modifier tells the insurer that the NP rather than the physician provided the service and the physician supervised the NP. Incident-to services are paid at 100 percent of the Medicare Physician Fee Schedule amount.

Insurers may apply a reduction to services billed directly under the NP’s NPI. Typical reduction is 15 to 20 percent.

Never heard of modifier SA? HCPCS Level II created the HIPAA compliant modifier to standardize NP reporting.

For instance, prior to February 2009, Medi-Cal previously used modifier YT (Nurse practitioner service [multiple modifiers]).